Paradoxical carbon dioxide embolism during laparoscopic surgery without intracardiac right-to-left shunt: two case reports and a brief review of the literature

We herein report two cases of paradoxical carbon dioxide (CO(2)) embolism during laparoscopic nephrectomy and hepatic left lateral lobectomy without evidence of a right-to-left shunt or obvious rupture of blood vessels. Transesophageal echocardiography detected paradoxical CO(2) embolism before the end-tidal CO(2) partial pressure (P(ET)CO(2)) dropped from baseline. The pneumoperitoneum was reduced or stopped immediately after detection of the embolism. One patient developed a postoperative epileptiform seizure. In the other patient, many gas bubbles were drawn out from the central venous line. We speculate that rapid introduction of pneumoperitoneum pushed a large amount of CO(2) into the abdominal blood vessels, exceeding the gas exchange capacity of the lung and causing CO(2) bubble formation in the left-side cardiac system. These two cases indicate that intraoperative transesophageal echocardiography can reduce the influence of CO(2) embolism during laparoscopic tumor surgery by early diagnosis of the embolism and provide helpful information to establish a list of differential diagnoses of postoperative complications.